Examkin

Question

Difficulty: MediumSubstance-Related and Addictive Disorders

A 28-year-old woman is brought to the emergency department by her sister due to severe agitation and paranoia. The sister reports that the patient has been awake for three days, pacing her apartment, and claiming that government agents are watching her through the smoke detectors. The patient has a past psychiatric history of bipolar I disorder. The sister suspects the patient recently began using "meth" (methamphetamine). The patient's medical record indicates that her father is her legally appointed healthcare proxy. Vital signs are temperature 38.2°C (100.8°F), blood pressure 165/100 mm Hg, pulse 122/min, and respirations 22/min. Physical examination shows diaphoresis, mydriasis, and extensive excoriations on her face and arms. She is highly combative, actively attempting to strike the nursing staff, and screaming, "I won't let you poison me!" Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Observe for one month to evaluate for schizophreniform disorder
  2. B
    Notify law enforcement regarding illicit substance use
  3. Administer intravenous lorazepamAnswer
  4. D
    Obtain treatment consent from the patient's sister
  5. E
    Initiate citalopram monotherapy for mood stabilization

Answer

The most appropriate next step in the management of this patient is to administer intravenous lorazepam.
The patient's presentation of severe agitation, paranoia, tactile hallucinations (suggested by the skin excoriations), mydriasis, diaphoresis, tachycardia, and hypertension is highly characteristic of acute methamphetamine intoxication. In the emergency setting, the primary goals of managing stimulant intoxication are to ensure patient and staff safety, control agitation, and prevent cardiovascular complications (e.g., myocardial infarction, stroke) and seizures. Benzodiazepines, such as intravenous lorazepam or diazepam, are the first-line treatment. They enhance GABA-A receptor activity, which suppresses the central nervous system hyperarousal, thereby effectively controlling both the severe agitation and the sympathomimetic hyperdynamic state (tachycardia and hypertension).

Step-by-Step Solution

1
Evaluate the clinical presentation and vital signs.
The patient exhibits severe agitation, paranoia, tactile hallucinations (evidenced by excoriations), mydriasis, diaphoresis, hyperthermia, tachycardia, and hypertension after suspected methamphetamine use.
Establishing the clinical toxidrome is required to correctly identify the primary cause of the acute behavioral and physical abnormalities.
2
Diagnose the underlying acute condition.
The constellation of a sympathomimetic toxidrome combined with psychotic features confirms acute methamphetamine intoxication.
Accurate diagnosis is crucial to select the correct pharmacological intervention and avoid contraindicated treatments.
3
Determine the most appropriate immediate management step.
Select intravenous lorazepam to treat the acute agitation and reverse the sympathomimetic hyperactivity.
Benzodiazepines safely reduce central nervous system hyperarousal, controlling the combative behavior and protecting against cardiovascular collapse and seizures.

Key Concept

Acute methamphetamine intoxication presents with a sympathomimetic toxidrome and agitation, and the first-line pharmacological treatment is benzodiazepines.
Rate this question

Topics

Substance-Related and Addictive Disorders

More questions from this topic